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Konno M, Niwa H, Kitayama M, Hirota K. Video versus ultrasound pupillometry for detecting increased pupillary diameters due to nociceptive stimuli: a prospective observational study. J Anesth 2024; 38:191-197. [PMID: 38189944 DOI: 10.1007/s00540-023-03297-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024]
Abstract
PURPOSE Ultrasound pupillometry (UP) is a potential alternative to video pupillometry (VP) for assessing changes in patients' pupillary diameter (ΔPD) due to surgical nociception, but the reproducibility of UP and VP has been unclear. We evaluated the reproducibility of nociceptive ΔPD measured with both methods. SUBJECTS AND METHODS This prospective observational trial with 15 healthy volunteers aged ≥ 18 years was conducted at a Japanese teaching hospital. The ΔPD due to tetanic stimuli randomly applied at 10-60 mA was measured with VP and UP. The primary outcome was the correlation between the ΔPD measured with VP and that measured with UP. The secondary outcome was the agreement between the methods. We also evaluated ΔPD pattern changes due to the raised pain intensity in each method. RESULTS The noxious ΔPD values of UP were weakly but significantly correlated with those of VP (Spearman's ρ = 0.38, p < 0.001). A significant constant error was identified between the two measurements (Bland-Altman: mean of the difference in ΔPD (VP - UP), - 0.4 [95% CI: - 0.52 to - 0.28, p < 0.001], generalized estimating equation: a beta estimator of ΔPD: 0.41, [95% CI: 0.26-0.56, p < 0.001]). The ΔPD pattern changes due to the raised tetanic stimuli were almost the same in the two methods. CONCLUSION Due to the significant constant error, we consider the reproducibility of the measured ΔPD between UP and VP moderate. Trial registry number UMIN 000047145. Prior to the subjects' enrollment, the trial was registered with the University Hospital Medical Information Network (Principal investigator: Mao Konno, Date of registration: 3.11.2022). https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053778 .
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Affiliation(s)
- Mao Konno
- Department of Anesthesiology, Hirosaki University Hospital, 53 Honcho, Hirosaki, Aomori, 036-8563, Japan
| | - Hidetomo Niwa
- Department of Community Medicine for Perioperative Management, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan.
| | - Masato Kitayama
- Department of Surgery, Hirosaki University Hospital, 53 Honcho, Hirosaki, Aomori, 036-8563, Japan
| | - Kazuyoshi Hirota
- Department of Community Medicine for Perioperative Management, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan
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Stefanini M, Cagnazzi E, Calza S, Latronico N, Rasulo FA. Feasibility of the pupillary pain index as a guide for depth of analgesia during opioid-sparing anesthesia with continuous infusion of dexmedetomidine. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:27. [PMID: 37580838 PMCID: PMC10424415 DOI: 10.1186/s44158-023-00112-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/04/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The pupillary dilation reflex (PDR) is an objective indicator of analgesic levels in anesthetized patients. Through measurement of the PDR during increasing tetanic stimulation (10-60 mA), it is possible to obtain the pupillary pain index (PPI), a score that assesses the level of analgesia. OBJECTIVES The depth of analgesia during opioid-sparing anesthesia (OSA) with continuous infusion of dexmedetomidine in addition to general anesthesia was assessed. DESIGN Observational prospective feasibility pilot study SETTING: This study was performed in the operating rooms of the Spedali Civili University-affiliated hospital of Brescia, Italy. PATIENTS Forty-five adults who underwent elective open (5-cm incision) surgery under general anesthesia (78% inhalation anesthesia), from Feb. 18th to Aug. 1st, 2019, were enrolled. Exclusion criteria were as follows: implanted pacemaker or ICD, ophthalmological comorbidities, chronic opioid use, peripheral neuropathy, other adjuvant drugs, epidural analgesia, or locoregional block. MAIN OUTCOME MEASURES The first aim was to verify the feasibility of applying a study protocol to evaluate the depth of analgesia during intraoperative dexmedetomidine administration using an instrumental pupillary evaluation. The secondary outcome was to evaluate appropriate analgesia, drug dosage, anesthesia depth, heart rate, blood pressure, transient side effects, postoperative nausea and vomiting (PONV), and pain numerical rating scale (NRS) score. RESULTS Thirty out of 50 patients (60%) treated with dexmedetomidine during the study period were included in the DEX group (8 males, age 42 ± 13 years, BMI 45 ± 8), and 15 other patients were included in the N-DEX group (8 males, age 62 ± 13 years, BMI 26 ± 6). Patients who underwent bariatric, abdominal, or plastic surgery were enrolled. At least 3 pupillary evaluations were taken for each patient. PPI ≤ 3 was observed in 97% of patients in the DEX group and 53% in the N-DEX group. Additionally, the DEX group received less than half the remifentanil dose than the N-DEX group (0.13 ± 0.07 vs 0.3 ± 0.11 mcg kg-1 min-1). The average dose of dexmedetomidine administered was 0.17 ± 0.08 mcg kg-1 h-1. CONCLUSION The feasibility of applying the protocol was verified. An OSA strategy involving dexmedetomidine may be associated with improved analgesic stability: a randomized controlled trial is necessary to verify this hypothesis. TRIAL REGISTRATION Trial.gov registration number: NCT05785273.
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Affiliation(s)
- Martino Stefanini
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123, Brescia, Italy.
| | - Elena Cagnazzi
- Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Stefano Calza
- Unit of Biostatistics and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, 25123, Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123, Brescia, Italy
| | - Francesco A Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123, Brescia, Italy
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Jin L, Liang Y, Yu Y, Miao P, Huang Y, Xu L, Wang H, Wang C, Huang J, Guo K. Evaluation of the Effect of New Multimodal Analgesia Regimen for Cardiac Surgery: A Prospective, Randomized Controlled, Single-Center Clinical Study. Drug Des Devel Ther 2023; 17:1665-1677. [PMID: 37309414 PMCID: PMC10257907 DOI: 10.2147/dddt.s406929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/23/2023] [Indexed: 06/14/2023] Open
Abstract
Objective To investigate the feasibility of multimodal regimen by paracetamol, gabapentin, ketamine, lidocaine, dexmedetomidine and sufentanil among cardiac surgery patients, and compare the analgesia efficacy with conventional sufentanil-based regimen. Design A single-center, prospective, randomized, controlled clinical trial. Setting One participating center, the cardiovascular center of the major integrated teaching hospital. Participants A total of 115 patients were assessed for eligibility: 108 patients were randomized, 7 cases were excluded. Interventions The control group (group T) received conventional anesthesia management. Interventions in the multimodal group (group M) were as follows in addition to the standard of care: gabapentin and acetaminophen 1 hour before surgery; ketamine for induction and to maintain anesthesia with lidocaine and dexmedetomide. Ketamine, lidocaine, and dexmedetomidine were added to routine sedatives postoperatively in group M. Measurements and Main Results The incidence of moderate-to-severe pain on coughing made no significant difference (68.5% vs 64.8%, P=0.683). Group M had significantly less sufentanil use (135.72µg vs 94.85µg, P=0.000) and lower rescue analgesia rate (31.5% vs 57.4%, P=0.007). There was no significant difference in the incidence of chronic pain, PONV, dizziness, inflammation index, mechanical ventilation time, length of stay, and complications between the two groups. Conclusion Our multimodal regimen in cardiac surgery is feasible, but was not superior to traditional sufentanil-based regimen in the aspects of analgesia effects; however, it did reduce perioperative opioid consumption along with rescue analgesia rate. Moreover, it showed the same length of stay and the incidences of postoperative complications.
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Affiliation(s)
- Lin Jin
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yafen Liang
- Department of Anesthesiology, University of Texas Health Center at Houston, Houston, TX, USA
| | - Ying Yu
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Peng Miao
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yihao Huang
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Liying Xu
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Huilin Wang
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Chunsheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine University of Louisville, Louisville, KY, USA
| | - Kefang Guo
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
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Ma D, Ma J, Chen H, Mu D, Kong H, Yu L. Nociception monitors vs. standard practice for titration of opioid administration in general anesthesia: A meta-analysis of randomized controlled trials. Front Med (Lausanne) 2022; 9:963185. [PMID: 36091708 PMCID: PMC9454957 DOI: 10.3389/fmed.2022.963185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Nociception monitors are being increasingly used during surgery, but their effectiveness in guiding intraoperative opioid administration is still uncertain. This meta-analysis of randomized controlled trials (RCTs) aimed to compare the effectiveness of nociception monitors vs. standard practice for opioid administration titration during general anesthesia. Methods We searched the electronic databases of PubMed, EMBASE, Cochrane Library, Clinical Trial, and Web of Science from inception up to August 1, 2021, to identify relevant articles, and extracted the relevant data. Intraoperative opioid administration, extubation time, postoperative pain score, postoperative opioid consumption and postoperative nausea and vomiting (PONV) were compared between patients receiving nociception monitoring guidance and patients receiving standard management. The standardized mean difference (SMD), with 95% confidence interval (CI), was used to assess the significance of differences. The risk ratio (RR), with 95% CI, was used to assess the difference in incidence of PONV. Heterogeneity among the included trials was evaluated by the I2 test. RevMan 5.3 software was used for statistical analysis. Results A total of 21 RCTs (with 1957 patients) were included in the meta-analysis. Intraoperative opioid administration was significantly lower in patients receiving nociception monitor-guided analgesia than in patients receiving standard management (SMD, −0.71; 95% CI, −1.07 to −0.36; P < 0.001). However, pain scores and postoperative opioid consumption were not significantly higher in the former group. Considerable heterogeneity was found among the studies (92%). Extubation time was significantly shorter (SMD, −0.22; 95% CI, −0.41 to −0.03; P = 0.02) and the incidence of PONV significantly lower (RR, 0.78; 95% CI, 0.61 to 1.00; P = 0.05) in patients receiving nociception monitoring guidance. Conclusions Intraoperative nociception monitoring guidance may reduce intraoperative opioid administration and appears to be a viable strategy for intraoperative titration of opioids. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=273619, identifier: CRD42019129776.
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Affiliation(s)
- Dandan Ma
- Department of Pain Management, Jinan Central Hospital, Shandong University, Jinan, China
- Department of Anesthesiology, Yidu Central Hospital Affiliated to Weifang Medical University, Weifang, China
| | - Jiahui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Huayong Chen
- Department of Anesthesiology, Yidu Central Hospital Affiliated to Weifang Medical University, Weifang, China
| | - Dongliang Mu
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Hao Kong
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Lingzhi Yu
- Department of Pain Management, Jinan Central Hospital, Shandong University, Jinan, China
- *Correspondence: Lingzhi Yu
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Niebhagen F, Golde C, Koch T, Hübler M. [Does NoL monitoring affect opioid consumption during da Vinci prostatectomy?]. DIE ANAESTHESIOLOGIE 2022; 71:683-688. [PMID: 35925157 PMCID: PMC9427871 DOI: 10.1007/s00101-022-01126-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/28/2022] [Accepted: 04/12/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Administration of opioids to suppress pain plays a major role in modern anesthesia. Measuring depth of hypnosis and neuromuscular recovery are already well established, and devices for pain monitoring are available. Nonetheless pain monitoring is rare in clinical practice. Recently, the pain monitoring device PMD200 (Medasense Biometrics™ , Israel) was introduced. It non-invasively measures heart rate, heart rate variability, skin resistance, resistance variability, temperature and movement to calculate a nociception level (NoL) index. The NoL index range starts at zero, which is equivalent to being painless, and goes up to a value of 100. The validity and reliability of NoL monitoring is the content of current studies. OBJECTIVE We tested the hypothesis if the use of the PMD200 significantly reduces opioid consumption during da Vinci prostatectomy. MATERIAL AND METHODS A total of 50 male patients were included in this randomized, single blinded study. Exclusion criteria were arrhythmia because the pain monitoring device requires a sinus rhythm for reliable results. Patients received a weight-adjusted sufentanil bolus (0.3 µg/kg ideal body weight) during induction of anesthesia. Additionally, they received 10 µg of sufentanil before skin incision. Both groups received total intravenous anesthesia with propofol and continuous muscle relaxation through cis-atracurium. In the control group (CONT; n = 26), a standardized sufentanil bolus of 10 µg were administered by common criteria (heart rate/blood pressure increase, lacrimation, gut feeling) at the anesthesiologist's discretion. In the intervention group (INT; n = 24), patients received the standardized sufentanil bolus when the NoL index was above 25 for 2 min, which corresponds to the manufacturer's recommendation. The NoL index and bolus administrations were recorded for every patient. In the control group, the display of the pain monitor showing the NoL index was not visible for the anesthesiologist. Postoperatively, pain/nausea scores and piritramide consumption were taken every 10 min for 1h in the recovery room. None of the patients had prior chronic pain with long-term use of painkillers. Statistics were done using Mann-Whitney U‑test, Kolmogorov-Smirnov test and Levene test. RESULTS Sufentanil bolus administrations, normalized for duration of surgery, were not significantly lower in the intervention group (p = 0.065). We noticed a significant difference in variation of opioid administrations (p = 0.033). Sufentanil boluses per hour in the INT were normally distributed (p = 0.2), whereas in CONT they were not (p = 0.003). Postoperative data like nausea, opioid consumption and pain scale showed no differences between groups. CONCLUSION The use of PMD200 did not significantly reduce cumulative opioid consumption. Following on we must reject the initial hypothesis. The difference in sufentanil bolus variances may point to an individualized antinociceptive therapy when NoL monitoring is used. We suppose patients with high opioid demands are detected and patients with low opioid demands did not receive unnecessary opioids. This assumption is only true if the PMD200 measures the entity pain. Further studies with more participants during surgery with higher tissue damage could lead to more convincing data and conclusions.
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Affiliation(s)
- F. Niebhagen
- grid.412282.f0000 0001 1091 2917Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Deutschland
| | - C. Golde
- grid.412282.f0000 0001 1091 2917Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Deutschland
| | - T. Koch
- grid.412282.f0000 0001 1091 2917Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Deutschland
| | - M. Hübler
- grid.4488.00000 0001 2111 7257Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Krankenhaus St. Joseph-Stift Dresden (Lehrkrankenhaus der TU Dresden), Dresden, Deutschland
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Abstract
The intraoperative dosing of opioids is a challenge in routine anesthesia as the potential effects of intraoperative overdosing and underdosing are not completely understood. In recent years an increasing number of monitors were approved, which were developed for the detection of intraoperative nociception and therefore should enable a better control of opioid titration. The nociception monitoring devices use either continuous hemodynamic, galvanic or thermal biosignals reflecting the balance between parasympathetic and sympathetic activity, measure the pupil dilatation reflex or the nociceptive flexor reflex as a reflexive response to application of standardized nociceptive stimulation. This review article presents the currently available nociception monitors. Most of these monitoring devices detect nociceptive stimulations with higher sensitivity and specificity than changes in heart rate, blood pressure or sedation depth monitoring devices. There are only few studies on the effect of opioid titration guided by nociception monitoring and the possible postoperative benefits of these devices. All nociception monitoring techniques are subject to specific limitations either due to perioperative confounders (e.g. hypovolemia) or special accompanying medical conditions (e.g. muscle relaxation). There is an ongoing discussion about the clinical relevance of nociceptive stimulation in general anesthesia and the effect on patient outcome. Initial results for individual monitor systems show a reduction in opioid consumption and in postoperative pain level. Nevertheless, current evidence does not enable the routine use of nociception monitoring devices to be recommended as a clear beneficial effect on long-term outcome has not yet been proven.
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Meyer-Frießem CH. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:330-331. [PMID: 34140086 DOI: 10.3238/arztebl.m2021.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Priebe HJ. Inappropriate Study Population. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:330. [PMID: 34140085 DOI: 10.3238/arztebl.m2021.0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ende J, Fassl J. Reducing Opioid Dose Via Targeted Nociception Monitoring. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 117:831-832. [PMID: 33593475 DOI: 10.3238/arztebl.2020.0831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Juliane Ende
- Institute of Cardiac Anesthesiology, Heart Center of the University Hospital Carl Gustav Carus, Technical University, Dresden, Germany; Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Technical University, Dresden, German
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